Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Complete Part 1 – Employee Information. This section must be filled out entirely. Enter your employer name, your name, and your complete address, ensuring you include the Box/Apt No., street number, city, province, and postal code. Make sure to also include your employee ID number.
3. Indicate whether this claim is an adjustment to a previously paid claim by selecting 'Yes' or 'No'. If 'Yes', ensure you have obtained authorization from your Benefit Administrator.
4. Move to Part 2 – Claimant Information. Here, you need to provide all necessary claimant details. Remember, original pharmacy receipts must be attached for drugs being claimed. Fill in the patient name, patient code (based on their relationship), date of birth, number of receipts, and amounts charged.
5. If applicable, complete Part 3 – Overage Student Information. Enter the name and address of the school attended if this applies to your claim.
6. Proceed to Part 4 – Coordination of Benefits. Indicate whether your spouse is covered by any other plans. If so, provide details of the other insuring agency or plan, group policy, and spouse’s date of birth.
7. If your claim involves medication purchased outside of Canada, fill out Part 5 – Out of Country Claim, indicating the country of purchase and the currency used.
8. Finally, certify that all information provided is complete and accurate by signing and dating the form. Remember to keep a copy of the completed form for your records.

Complete your Assure Telus Health online forms now to ensure timely processing.